Are you having any problems with your vision? [ ] Yes [ ] No If yes: [ ] Far Away [ ] Close Up [ ] In Between What type of work do you do? Do you use a computer? []Yes []No Reading: [ ] Extended Reading { ] Very Close/Fine Detail Do you have problems with bright lights or glare? | oD [ ] Yes [ ] No If yes, when do you notice this? [ ] On-coming headlights [ ] Computer Screen [ ] Glare from windshield — [ ] Sunlight What sun protection do you currently wear? What hobbies/activities do you enjoy? Do you engage in any activities that could cause eye injury? Are you currently a contact lens wearer? [ ] Yes What do you like [Y] dislike [NJ about your contacts? [ ] Vision [ ] Comfort { ] Convenience { ] Dryness Have you ever worn contacts? [Y] [N] Do glasses get in the way of any activities? (golf, swimming, etc.) [ ] No Would you like to explore the latest advances In contact lenses? { ] Yes { ]No What do you like [Y] dislike [N] about your current eyewear? []Weight []Thickness [ ] Fit [ ] Style {[ ]Shape [ ] Durability []Size [ ] Color White Copy — Patient Yellow Copy — Dispenser Pink Copy — File EX-067-LC LENSCRAFTERS 1199 FIRST AVENUE 1199 FIRST AVENUE AT 65TH STREET NEW YORK, NY 10021 ; 77 7} 10 Patient Name’ { Date: __ . Sun: Sphere "| Cylinder | Axis | Prism Add engle Vision ~ T ~T es a | [ } Progressive + . | [ ] Bifocal AS = ! Trifocal | 1 . } Distance os |19 26 |-0,45 0”0 [ ] Near Work/Primary: : : | Sphere | Cylinder Axis” | Prism Add ~ ifr seoe os ~~ . op |: —- 1 — - . Bifocal +1 4% + . - - [ ] Trifocai ‘s YY { ] bi OS | 3,26 |-0. 25 | O10 (1Near Computer, 12 ¢ ad ( ant Sphere | Cylinder | Ax T Prism | Add? | Add? — —- —- en i ees oD | | | ] Progressive ty vO! 7 | i 7 [ jPRIO . OS |, i) 50|-0,26 | 090 | — Safety/Specialty Sphere | Cylinder Axis Prism Add iF 5 Sigh ~ : | i oD | | ] Bifocal _ _ [ ] Trifocat os | | | | | [ ] bistance [ ] Near | tan < YWren = OD. oe OD License # “Wb Tprpires: SG _! L (f [] Yes [] Yes [] No [] No Po. L_... mm CP#3008024 EFTA00553155